Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Emergency Department Clinician Perceptions of Implementing High-Sensitivity Troponin T Assay in an Academic Hospital Emergency Department.

PURPOSE: A newly approved, high-sensitivity troponin T (hsTnT) assay may offer opportunities to more rapidly assess for acute coronary syndrome and identify lower thresholds of myocardial injury. As more emergency departments begin to use the hsTnT assay, anticipating barriers to hsTnT implementation success are critical to realizing potential benefits in rapid, accurate patient assessment. METHODS: At a tertiary health system emergency department, hsTnT was implemented along with a diagnostic algorithm and a decision tree to aid in utilization. Qualitative interviews with 18 physicians and advance practice providers were conducted 2 months' postimplementation and again 4 to 6 months postimplementation to capture clinician perceptions to hsTnT implementation efforts. Deductive coding was performed using implementation science determinants frameworks to identify emerging themes related to this topic. RESULTS: Four themes emerged from the interviews: 1) the need for additional clinician education, 2) challenges with care handoffs, 3) lack of buy-in from the hospital community, and 4) key successes. CONCLUSION: Interviews demonstrated that implementation of hsTnT was associated with several implementation barriers from the perspective of emergency department clinicians. Future implementation efforts should focus on diverse and sustained staff educational efforts, models that address challenges with care handoffs between emergency department clinicians and inpatient clinicians, and operational teams that include inpatient clinicians to facilitate buy-in.

Development of an artificial placenta: CO2 elimination and hemodynamics as a function of arteriovenous blood flow.

BACKGROUND: As a first step toward the development of an artificial placenta, we investigated the relationship between blood flow rate through an arteriovenous (A-V) circuit/oxygenator and both CO2 elimination and hemodynamic stability in a small animal model. METHODS: Male New Zealand rabbits (N = 10) with an average weight of 2.7 +/- 0.2 kg were anesthetized, paralyzed, and heparinized before carotid-jugular cannulation. A tracheostomy tube, an arterial catheter, and an aortic flow probe were placed. Arteriovenous flow through a custom-made, low-resistance, 0.5 m2 hollow fiber oxygenator was initiated. Oxygen sweep flow was maintained at 300 mL/min, whereas blood flow was controlled at 10 to 40 mL/(kg min). Ventilation was discontinued during each blood flow rate trial. Hemodynamic and preoxygenator and postoxygenator blood gas data were recorded 30 minutes after initiation of each flow rate. CO2 removal was the product of the oxygen sweep gas flow rate and the sweep flow exhaust CO2 content as determined by capnometry. Data were analyzed by analysis of variance with post hoc Dunnett's t test. RESULTS: CO2 removal increased and PaCO2 decreased as a function of A-V blood flow rate. Simultaneously, systolic blood pressure did not significantly change. CO2 removal was effective at device flows greater than 20% of cardiac output. CONCLUSION: In this rabbit model, A-V blood flows at 25% to 30% of cardiac output allow full gas exchange without hemodynamic compromise. This model raises the possibility of using A-V support and an artificial placenta in newborns with respiratory failure.